RT 306 Lesson 1&3 Pre-Final PDF

Pre-Final 1 Part 1: Quality Assurance and Quality Control Quality Assurance Routine Periodic Evaluation of the Ultrasound System to guarantee optimal image quality. Quality Assurance Goals 1. Proper Equipment Operation 3. Minimal Downtime 2. Detect Gradual Changes...

Pre-Final 1 Part 1: Quality Assurance and Quality Control Quality Assurance Routine Periodic Evaluation of the Ultrasound System to guarantee optimal image quality. Quality Assurance Goals 1. Proper Equipment Operation 3. Minimal Downtime 2. Detect Gradual Changes 4. Reduce Number of Repeat Scans 2. Tissue Equivalent Phantom Quality Assurance Requirements Ultrasonic Features similar to Soft Tissue. 1. Assessment of System Components 3. Preventive Maintenance Strategically located pins, structures that mimic cysts & solid masses embedded in phantom 2. Repairs 4. Record Keeping Role of Sonographer Perform Quality Assurance Although the Manufacturer’s Service Engineer may be involved, the ultimate responsibility for Quality Assurance always rests with the Sonographer. It is important to validate the Reliability of the Images produced and Measurement made with each Transducer. 3. Doppler / Flow Phantom Quality Assurance Tests Assess accuracy of Pulsed, Continuous Wave, Power, & Color Flow Systems. AIUM 100mm Test Object Tissue Equivalent Phantom Doppler Phantom 1. Vibrating String 2. Moving Belt Phantom 1. AIUM 100mm Test Object Performance Measures Fluid-Filled Tank containing strategical located Stainless-Steel Pins or Plastic Strings. Sensitivity: is the Ability to Display Low Echoes with a Tissue Equivalent Phantom. Speed of Sound in AIUM Object is identical to Soft Tissue. AIUM Object don’t have attenuation property of Soft Tissue - Grayscale can’t be evaluated. Part 2: Interventional Ultrasound Placing the transducer on Top, Sides, and on the Oblique side of the object provides a variety Advantages of Ultrasound Guided Interventional Procedures: of orientations between the sound beam and pins. Axial Resolution: evaluated when pins in the test object are parallel to the sound beam’s main axis. The needle tip is directed, in real time, along the biopsy path and visualized within the lesion. Greater Precision. Lateral Resolution: evaluated when pins in the test object are perpendicular to the sound beam. The best route can be utilized and vital structures (blood vessels) can be avoided. Ultrasound guided biopsies are quick, safe, and accurate. Electronic Caliper Accuracy: evaluated by comparing the distances between reflections on the display with the actual distances in the test object. Ultrasound-Guided Interventional Procedures: Dead Zone: evaluated by scanning pins located at the top of test object, very close to transducer. Aspiration Drainage Biopsy 1. Aspirations Cysts Aspiration Cysts are common, usually diagnosed accurately with USD. Causing significant Tenderness. Cysts Aspiration Technique Patient Position: depending on the Location. Skin is cleaned, numbed with Topical Anesthesia. 2. Drainage Using USD guidance, a small needle is advanced into the cyst and suction is applied to draw the fluid out, causing the lump to collapse. Abscess Drainage Procedure allows Collections which would otherwise require Open Surgery to be drained via Skin Incision only. Minimally Invasive Technique. Abscess Drainage Technique Abscess is first delineated & safe route from skin to the Abscess Cavity. Catheter is introduced into the Abscess Cavity. USD Guided Paracentesis Once in position, the Catheter is secured and attached to a Drainage Bag. Ultrasound Guided Drainage Get an USD scan of the Ascites before procedure. Radiologist marks spot for Paracentesis. 2 Things to Consider: 1. Distance from the skin to the fluid (usually 1 cm). 2. Distance to the midpoint of the collection (usually 3 cm). Ultrasound Markings 3. Fine-Needle Aspirate & Biopsy Percutaneous Needle Biopsy provides reliable diagnosis of both Benign and Malignant disease and is a proven Alternative to Open Surgical Biopsy. USD Guided Thoracentesis Patient should be Sitting or in Lateral Decubitus with Pleural Effusion Side Up. Marker of the Probe should be pointed towards the Head. Diaphragm of Liver / Spleen should be identified first. Probe can then be moved towards the Head and/or from side to side to locate the largest pocket of fluid between Ribs. Image Documentation Criteria Patient’s Name and Identification Number. Date and Time. Scanning Site. Name and Initials of the Sonographer. Transducer megahertz. Area of Interest. Patient Position. Scanning Plane. Ultrasound Scanning Methods Ultrasound Scanning Planes 1. Perpendicular 2. Angled Sagittal Transverse Coronal 3. Subcostal 4. Intercostal 5. Tilting Part 3: Cranial Ultrasonography Image Documentation Criteria Anatomy and Sonographic Appearance of the Brain 1. Cerebrum 3. Four Ventricles of the Brain Largest Part of the Brain; is divided into Right and Left Hemisphere. Interhemispheric Fissure. Sonographic Appearance: Midgray with Medium-Level Echoes. 2 Lateral Ventricles Cerebrospinal Fluid-Filled Cavities within each Cerebral Hemisphere. Sonographic Appearance: Echogenic and Curvilinear. These Slit-Like Structures lie the same distance from the Interhemispheric Fissure. Ventricle Cavities contains CSF and appear Anechoic. 2. Cerebellum Normal Ventricles 2nd-Largest Portion of the Brain. Lateral Ventricles in most Infants measure less than 2 - 3mm in diameter. Lies immediately Posterior to the 4th Ventricle. Occupies the majority of the Posterior Fossae of the Skull. Sonographic Appearance: Parenchyma appears Midgray or as Medium-Level Echoes. Central Echogenic Portion of the Cerebellum is the Vermis. Parietal Lobe Middle Part of the Brain. Parietal Lobe helps a person Identify Objects. Occipital Lobe Third Ventricle Back Part of the Brain. Small, Teardrop-Shaped, Midline Cavity that lies between the Thalami and is connected to Involved with Vision. the Lateral Ventricles via the Foramen of Monro. Temporal Lobe Fourth Ventricle Involved in Short-Term Memory, Speech, Musical Rhythm, and some Smell Recognition. Small, Thin, Arrowhead-Shaped, Midline Cavity that appears to project to the Cerebellum. Located Below & connected to the 3rd Ventricle by a small channel, Aqueduct of Sylvius. Frontal Lobe Sonographic Appearance: Controls High-Level Cognitive Skills and Primary Motor Functions. Walls appear Echogenic. The Cavity contains CSF and appears Anechoic.  7. Cisterna Magna 4. Thalamus Largest Expanded Subarachnoid Space in the Brain. Two Large, Egg-Shaped Thalami lie on each side of the 3rd Ventricle, forming most of its Located at the Base of the Cerebellum in the Posterior Portion of the Brain. Lateral Walls. Sonographic Appearance: Sonographic Appearance: Cavity contains CSF and appears Anechoic. Homogeneous and Midgray with Medium-Level Echoes. 5. Corpus Callosum Flat, Broad Nerve Fibers between the Right and Left Cerebral Hemispheres that form the Roof of the Lateral Ventricles. Sonographic Appearance: The Parenchyma appears Midgray or as Medium-Level Echoes. 8. Choroid Plexus Special Blood Vessels located in the Ventricles that produce CSF. Sonographic Appearance: Consists of 2 Curvilinear, Highly Echogenic Structures. 9. Aqueduct of Sylvius 6. Cavum Septum Pellucidum (Anterior Portion) and Cavum Vergae (Posterior Portion) Midline Channel that connects the 3rd and 4th Ventricles. Small Cavities filled with CSF that filters from the Ventricles through the Septal Laminae. They have no connection with the Ventricles. They separate the Frontal Horns of the Lateral Sonographic Appearance: Ventricles, forming their Medial Margins at the Midline of the Brain. Closes before Birth. Rarely seen Sonographically unless Dilated. Sonographic Appearance: Appear Moderately Gray and Comma-Shaped Sagittally or Triangular Coronally.  Sonographic Appearance: Thin, Linear, Echogenic, Midline Structure. 10. Foramen of Monro Narrow, Midline Channels that connect the 3rd Ventricle with each Lateral Ventricle for 13. Massa Intermedia the passage of CSF. Pea-Shaped, Soft Tissue Structure suspended within the 3rd Ventricle with no function. Sonographic Appearance: Sonographic Appearance: Anechoic area just Posterior to the Level of the Frontal Horn of each Lateral Ventricle. Midgray with Medium-Level Echoes and is best seen with Ventricular Dilatation. 11. Brain Stem 14. Hippocampal Gyrus (Choroidal Fissure) Columnar-Appearing Structure that connects the Forebrain and the Spinal Cord. Consists of the Midbrain, Pons, and the Medulla Oblongata. Convolution on the Inner Surface of the Temporal Lobe of the Cerebrum. Sonographic Appearance: Sonographic Appearance: Midgray with Medium to Low-Level Echoes. Echogenic, Spiral-Like Fold embodying each Temporal Horn. 12. Interhemispheric Fissure 15. Cerebral Peduncle Deep Groove or Indentation separating the Right and Left Cerebral Hemispheres. Contains the Falx Cerebri. Y-Shaped Structure Inferior to the Thalami and fused at the Level of the Pons. Sonographic Appearance: Midgray with Low-Level Echoes. 16. Sulci Grooves separating the Gyri on the Surface of the Brain. Sonographic Appearance: Echogenic, Spider-Like Fissures separating the Gyri or Folds of the Brain. The Premature Neonate usually has fewer Sulci than a Full-Term Infant. 19. Caudate Nucleus Located within the Concavity of the Lateral Angles of each Lateral Ventricle. Sonographic Appearance: Midgray with Medium-Level Echoes. 17. Tentorium Dura Mater Flap that separates Cerebral Hemispheres from other structures in the Brain. Sonographic Appearance: Echogenic Structure (Tent-Shaped Coronally). 20. Germinal Matrix / Caudothalamic Groove Vascular Network located in the Region of the Caudate Nucleus and Thalamus called the Caudothalamic Groove. Sonographic Appearance: When visualized, it appears Small and Echogenic. Note that this is the most common site for a Subependymal Hemorrhage. 18. Sylvian Fissure Groove separating the Frontal and Temporal Lobes of the Brain. Sonographic Appearance: Resembles an Echogenic “Y” turned on its side. The Middle Cerebral Artery can be seen Pulsating here. Normal Size Values At Birth Circumference of Head: 13 - 14 inches. First 3 Months of Life: increases 17%. 6 Months: increases 25%. Indications Routine head USD for premature neonates’ suspicion of brain anomalies on antenatal USD. Any sick neonate in whom brain pathology is implicated. A neonate that had not been screened prenatally. Anterior Fontanelle Planes Preparation Keeping the baby warm is of utmost importance. The baby should be disturbed as little as possible, preferably left in the Isolette. If the baby is in a high-oxygen environment, this should be maintained as much as possible, even though the baby must be scanned there. Gowns and gloves are recommended. The portable ultrasound system should be wiped down with a cleaning agent. Coupling gel should be at body temperature. Transducer Coronal Survey 7.5 MHz: for Premature Infants less than 32 weeks' Gestation or less than 1500 g. Begin with the transducer perpendicular at the anterior fontanelle. 5.0 - 3.0 MHz: for Term and Older Infants with Open Anterior Fontanelle. Slowly angle the transducer to the face. Scan through frontal horns to frontal lobes of brain. Slowly angle the transducer back to perpendicular. Slowly angle the transducer posteriorly. Scan through the occipital horns into the occipital lobes of the brain. Slowly angle the transducer back to perpendicular. The 6 Standard Images Should be Aimed at the Planes Shown in Figure. Patient Position Supine with the head face up. Prone with the head lying on either side. It can be helpful to place a small cloth or towel under and/or beside the baby's head to help immobilize it during the scan. Scanning Technique (Neonatal Brain Survey) 1. Coronal Survey 2. Sagittal Survey Acoustic Windows The Location from which Ultrasound Waves Permeate the Deep Structures. Coronal Standard Image: c1 Frontal Lobes (2) separated by Cerebral Falx (1), lying on Bright Hyperechoic Lines, Supra-Orbital Ridges (3). Coronal Standard Image: c5 At the level of Trigone of the Lateral Ventricles. Coronal Standard Image: c2 At the level of Frontal Horns of the Lateral Ventricles. Coronal Standard Image: c6 Through the Parieto-Occipital Lobe. Extra Axial Space. Coronal Standard Image: c3 At the level of Foramen of Monro and the 3rd Ventricle. Sagittal Survey Begin with the transducer perpendicular at the anterior fontanelle. Slowly angle the transducer laterally toward the right lateral ventricle. Scan through the Coronal Standard Image: c4 temporal lobe of the brain to the level of the sylvian fissure. At the level of the Bodies of the Lateral Ventricles. Slowly angle the transducer back to perpendicular. Repeat the 1st, 2nd, and 3rd steps, but angle the transducer through the left hemisphere. The 6 Standard Images Should be Aimed at the Planes Shown in Figure. 2. Frontal Horn Cyst Elliptical, Smooth, Thin-Walled Cysts adjacent to the tip of the Anterior Horns of the Lateral Ventricles. Sagittal Standard Image 3. Agenesis of Corpus Callosum High-Riding 3rd Ventricle. Complete or Partial (usually of the Posterior Part) absence of the Corpus Callosum in a Mid- Sagittal View of the Brain. 4. Choroid Plexus Cyst Single or Multiple Cystic Areas (> 2 mm in diameter) in one or both Choroid Plexuses of Pathologies the Lateral Cerebral Ventricles. 1. Hydrocephalus A Neurological Disorder caused by an Abnormal Buildup of CSF in the Ventricles (Cavities) deep within the Brain. Dilated Ventricles with Increased Head Circumference. God will take care of you… Pre-Final 2: Whole Abdomen Ultrasonography Sonographic Appearance of Liver Liver Homogenous, moderately Echogenic. Anechoic Tubular Structures in the Parenchyma representing Blood Vessels & Biliary Ducts. Largest Solid Organ in the body. Occupying much of the Right Upper Quadrant. It weighs 1600 grams in males and 1400 grams in females. Covered by Glisson Capsule. Sonographic Appearance of Hepatic Vein Sonographic Appearance of Portal Vein The Liver is divided into 8 functional segments based on Vascular and Biliary Anatomy. Sonographic Appearance of Bile Ducts Liver Spaces Morison’s Pouch: Lateral to the Right Lobe of the Liver, Anterior to the Kidney. Subhepatic Space: Space between Inferior Edge of the Right Lobe and Anterior to the Right Kidney. Subphrenic Space: Space between Diaphragm and Superior Border of Liver. Preparation for Whole Abdomen USD NPO: 8 - 12 hours. This ensures Normal Gallbladder and Biliary Tract Dilatation and reduces the Stomach and Bowel Gas Anterior to the Pancreas. If the patient has eaten, still perform the examination. Indication for Examination 1. Abnormal Liver Function Tests (LFT) 2. Biliary Disease 3. Hepatocellular Disease Pathologic Processes of the Liver Yellowish Discoloration of the Skin and Eyes Pale Stools 1. Hepatic Cyst Abdominal Pain Intermittent Blood in the Stools Cysts: are common and easily identified and characterized by USD. Distension of the Abdomen Extreme Fatigue Benign Hepatic Cysts: contain Anechoic Fluid and have Thin Walls. Severe Itching of Skin Nausea Dark or Tea colored Urine Loss of Appetite Most are Septated. Vary in size. Tiny to Huge and commonly multiple, producing bunch of Grapes Appearance. Small Cysts: may mimic Vessels on quick inspection. 4. Abdominal Pain 8. Ascites Doppler: is useful to confirm that they’re Avascular. 5. Post Prandial Pain 9. Jaundice Sonographic Appearance: 6. Palpable Liver / Enlarged Liver 10. Abdominal Trauma 7. Pancreatitis 11. Liver Abscess Anechoic Round or Oval Shaped Mass. Well-Defined, Smooth Wall Margins. Posterior Acoustic Enhancement May contain Septations or Low-Level Internal Echoes. Patient Position Scanning Technique: Supine Transducer: 3.0 - 3.5 MHz Breathing Technique: Deep, Held Inspiration. 2. Echinococcal Cyst Gain Setting: Should allow Diaphragm to be clearly seen. Caused by Cyst-Like Tapeworm Larvae growing in the body. Scanning Technique Right Upper Quadrant Pain. Leukocytosis: elevated WBC count Begin with the Transducer Perpendicular to the Midline of the body. Fever Use Subcostal Angle and move the Transducer to the Left, Lateral and Inferior along the Hepatomegaly Costal Margin. Scanning should be done in Slow Rocking Movement of Transducer for best visualization. Sonographic Appearance: Normal Values Septated Cystic Mass (Honeycomb) Mobile Internal Echoes (Snowflakes) Liver: Sagittal Length 13 - 15 cm. Cyst containing Smaller Cysts. Collapsed Cyst within a Cyst (Water Lily Sign) Common Bile Duct Round or Oval in shape. < 6 mm. Smooth Wall Margins. < 9 mm: s/p Cholecystectomy. Portal Vein: 13 - 15 mm. 3. Budd Chiari Syndrome 5. Hepatic Hemangioma An Uncommon Disorder characterized by Obstruction of Hepatic Venous Outflow. Homogenously Hyperechoic in comparison to adjacent structures. Abdominal Pain Smooth Outline, Hepatic Vein can be seen in the immediate vicinity. Hepatomegaly Most are Small, but can be quite Large. Lower Extremity Edema Larger Hemangiomas: are Heterogenous. Mild Increase in Alkaline Phosphatase Sonographic Appearance: Hypoechoic Intraluminal Echoes in the Hepatic Veins. Dilated Hepatic Veins Vein Wall Thickening Absence of or Altered Hepatic Venous Flow. Hepatomegaly Ascites Hyperchoic Liver Parenchyma 6. Focal Nodular Hyperplasia Thrombosis in the Portal Veins. Asymptomatic Discrete, Lobulated Hyperechoic Mass located adjacent to the Liver Capsule. Other Patterns: Hypoechoic and Isoechoic to the Normal Liver Parenchyma. Hyperechoic Star Shaped Area in the Central Portion of the Tumor. 4. Liver Cell Adenoma Long History of Usage of Oral Contraceptives. Normal Labs RUQ Pain 7. Cirrhosis Sonographic Appearance: USD reflects the Morphologic Changes in the Liver associated with Cirrhosis. Hepatic Echotexture is Coarsened & Heterogeneous, with Numerous Vague Nodules evident. Range from Hypoechoic to Hyperechoic and may contain areas of Internal Hemorrhage, In High-Frequency Transducers, the surface of the Liver shows Fine or Coarse Nodularity. Necrosis, Fibrosis, or Calcification.  Alcoholism is most common cause. Abdominal Pain 9. Hepatic Abscess Biliary Obstruction Ascites Abdominal Pain Viral Hepatitis Elevated aspartate aminotransferase & bilirubin Fever and Chills Budd-Chiari Syndrome Skin changes and Hair loss Nutritional Deficiencies Non-Obstructive Jaundice Leukocytosis Cardiac Disease Enlargement of Caudate Lobe Elevated Alkaline Phosphatase Weakness and Fatigue Splenomegaly Jaundice Weight Loss Ascites Hepatomegaly Complex Mass Right Lobe Sonographic Appearance: Oval or Round in Shape Irregular Wall Margins Diffuse Increase in Parenchymal Echogenicity. Usually, Solitary Irregular Nodular Contour. Posterior Acoustic Enhancement Inability to Distinguish Portal Vein Wall Margins. 10. Fatty Infiltration 8. Candidiasis Asymptomatic Immune Suppressed Patients Elevated Liver Function Tests Abdominal Pain Hepatomegaly Fever and Chills Palpable Liver Sonographic Appearance: Sonographic Appearance: Diffuse Increase in Parenchymal Echogenicity. Normal Vessel Wall Margins. Uniformly Hypoechoic Lesions within the Liver Parenchyma. Thick Wall Margins Hepatomegaly May demonstrate a Target or Wheel within a Wheel Appearance. Hyperechoic Lesions with Posterior Acoustic Shadowing. 11. Hepatic Steatosis Clinical Findings 12. Hepatocellular Carcinoma Asymptomatic Hepatocellular Carcinoma may be Solitary, Multifocal, or Diffuse. Elevated Liver Function Test Detection in the Diseased Liver is commonly difficult with US. Hepatomegaly Most are Hypervascular, with Prominent Vascularity shown by Color Doppler. Tumor Invasion of the Portal and Hepatic Veins is common. Classification Fatty Infiltration Tumors may be Hyperechoic with Internal Fat to Hypoechoic and Heterogeneous because of Grade 1: Slight Diffuse Increase in the Hepatic Parenchyma with normal visualization of the Non-liquefactive Necrosis. Diaphragm and Intrahepatic Vessel. Any Solid Mass detected by US in diseased liver is suspicious for Hepatocellular Carcinoma. Grade 2: Moderate Diffuse Increase with Slightly Impaired Visualization. Palpable mass. Grade 3: Marked Increase with poor or no visualization of the Intrahepatic Vessel Borders, Elevated alanine aminotransferase, aspartate aminotransferase and alkaline phosphatase. Diaphragm and Posterior Portion. Abdominal Pain Solid Mass with Variable Echogenicity Weight Loss Mat demonstrates Hypoechoic Halo Unexplained Fever Multiple Nodules Positive Alpha Fetoprotein Hepatomegaly Jaundice Ascites Causes of Hepatic Steatosis 1. Obesity 5. Hepatitis 2. Bad Habits 6. Alcohol Abuse 3. Diabetes 7. Hyperlipidemia 4. Cirrhosis 8. Metabolic Disorder 13. Hepatic Metastases Hepatomegaly RUQ Pain Weight Loss Loss of Appetite Jaundice Increase in AST, ALT and Bilirubin Mild Increase in Alkaline Phosphatase. Sonographic Appearance: Bull’s Eye or Target Lesion. Hyperechoic Masses Cystic Masses Complex Masses Diffuse Pattern Bile Ducts Normal Extrahepatic Bile Ducts Functions of Biliary System Longitudinal Plane Transport Bile to the Gallbladder through the Bile Ducts. Anechoic Non-Vascular Tubular Structures Anterior to MPV and PHA Store and Concentrate Bile in the Gallbladder. Smooth Hyperechoic Walls Transport Bile through the Bile Ducts through the Duodenum. Intraluminal diameter 6 mm or less. Transverse Plane Anechoic Non-Vascular Tubular Structure Smooth Hyperechoic Walls Biliary Ducts – Intrahepatic and Extrahepatic Abnormal Bile Ducts Intraluminal diameter exceeding 6 mm. Thick, Irregular, Non-Parallel Wall. Common Hepatic Duct Normal Values 4 mm - 6 mm (CHD) Starting at age 60, CBD may increase in diameter by 1 mm per decade. Gallbladder Sonographic Appearance Functions of the Gallbladder Normal Intrahepatic Bile Concentrates Bile through the Gallbladder Epithelium. Anechoic Non-Vascular Tubular Structures. Stores Concentrated Bile. Smooth Hyperechoic Walls. Contracts to Release Bile. Intraluminal diameter 4 mm. Gallbladder Division Left and Right Hepatic Bile Ducts generally lie Anterior to the corresponding Portal Vein.  Abnormal Fasting Gallbladder Transverse diameter above 5 cm. Thick or Edematous Wall 3 mm. Irregular Wall Contour Intraluminal Focus or Echoes Acoustic Shadowing Posterior to the Gallbladder Fossa. Reasons for Non-Visualization of Gallbladder Non-Fasting Patient Surgically Absent Anatomical Variants of Gallbladder Obliteration of the Gallbladder Lumen by Intestinal Air or Gallstone. Patient Body Habitus Hartmann Pouch Junctional Fold Phrygian Cap Ectopic Location Agenesis Non-Inflammatory causes of Gallbladder Wall Thickening Non-Fasting Patient Congestive Heart Failure Ascites Hypoalbuminemia Cirrhosis Acute Hepatitis If there is No Contraction: Search For Gallstone or any cause of Obstruction in the Common Bile Duct. Location of the Gallbladder Empyema: Gallbladder is distended with thick walls and filled with fluid. Mucocele: Gallbladder is distended with thin walls and filled with fluid. Located in the Gallbladder Fossa on the Posterior Surface of the Gallbladder. Examination Technique Lateral to the Inferior Vena Cava, Anterior and Medial to the Right Kidney. Sonographic Appearance Supine, Oblique, Decubitus, or Erect. Intraluminal Measurement Normal Fasting Gallbladder In Jaundice patients, careful evaluation of the Intrahepatic Ducts is warranted. Intrahepatic Ducts, Extrahepatic Ducts should always be evaluated. Ellipsoid Anechoic Structure in Gallbladder Fossa with Posterior Acoustic Enhancement. After Supine Position, patient is positioned in the Oblique Views to demonstrate Mobility of Demonstrates Smooth Hyperechoic Walls < 3 mm. the Gallstones or Avoid Obscuring Bowel Gas Patterns. Located in the Inferior Medial Aspect of the Liver. Indication for Examination RUQ Pain Post Prandial Pain Increase in the Liver Function Tests Positive Murphy Sign Nausea / Vomiting Jaundice Intolerance to Fatty Foods Pyrexia of Unknown Origin Pathology 1. Pneumobilia Sonographic Appearance: Presence of Gas in the Biliary System. Echogenic Intraluminal Focus Etiology: Surgical Procedure, Trauma, Infection. Immobile Clinical Findings: Asymptomatic, RUQ pain. Non-Shadowing Thickening of the Gallbladder Wall Sonographic Appearance: 4. Adenomyomatosis Hyperechoic Focus in the Intrahepatic Bile Ducts. Comet Tail Artifact often Centrally Located. Hyperplasia of the Epithelial and Muscle Layers of the Gallbladder Wall. Clinical Findings: Asymptomatic, Dull RUQ Pain, Intolerance to Fatty Foods. 2. Biliary Ascariasis Sonographic Appearance: Worms that colonize the Intestinal Tract may their way into the Biliary Tree and Gallbladder. Obstructs Biliary Tree & Gallbladder. Causes Cholangitis, Cholecystitis, Pancreatitis, Mortality Echogenic Intraluminal Focus Etiology: Ingestion of Contaminated Water or Food. Diffuse Comet Tail Artifact Clinical Findings: RUQ Pain, Fever, Leukocytosis. Immobile Sonographic Appearance: Spaghetti-like Moving Tubular Echogenic structures with an Echolucent core in a bile duct. Non-Shadowing Posterior Acoustic Enhancement 5. Echogenic Bile Bile becomes Echogenic when it is Highly Concentrated and Cholesterol Crystals and Calcium Bilirubinate Granules Precipitate as Sludge. Sludge: layers in Gallbladder, becomes viscous & form Sludge Balls / Tumefactive Sludge Sludge Balls: usually move within the gallbladder but do not cast acoustic shadows. 3. Gallbladder Polyp Etiology: Prolonged Fasting, Biliary Stasis & Obstruction, Cholecystitis, Sickle Cell Anemia. Clinical Findings: Asymptomatic, RUQ Pain, Nausea, Vomiting. Echogenic Non-Shadowing Nodules that extend from the Gallbladder Wall. Mixture of Particulate Solids that have precipitated from Bile. Cholesterol Polyps: mostly. Which are < 1 cm and are commonly Multiple. Sonographic Appearance: Adenomatous Polyps: are rare and indistinguishable from Cholesterol Polyps. Benign Epithelial Tumor Non-Shadowing Low Amplitude Echoes layering in the Dependent portion of the Gallbladder, Clinical Findings: Asymptomatic, Dull RUQ, Intolerance to Fatty Foods. echoes move slowly with position change, may fill the entire organ.  Sonographic Appearance: Small Contracted Gallbladder Thick Hyperechoic Walls Cholelithiasis, 90% of cases Posterior Acoustic Shadowing Positive Murphy Sign Sludge 6. Cholelithiasis Ultrasound: imaging method of choice for detection of Gallstones with sensitivity of > 90% Gallstones: appear within the Gallbladder Lumen as Echogenic Objects that cast Acoustic 8. Mirrizi Syndrome Shadows and Move with changes in patient position. Etiology: impacted stone in the Gallbladder Neck or Cystic Duct, obstruction of CHD. Etiology: Abnormal Bile Composition, Bile Stasis, Infection. Clinical Findings: RUQ Pain, Jaundice, Elevated Bilirubin, Alkaline Phosphatase, ALT, AST Risk Factors: Family History, Obesity, Pregnancy, Diabetes, Female Prevalence 4:1 Clinical Findings: Asymptomatic, RUQ Pain, Epigastric Pain, Chest / Shoulder Pain, Sonographic Appearance: Elevated Liver Function Tests, Nausea, Post Prandial Pain, Fatty Food Intolerance. Immobile Calculus in the Cystic Duct or Neck of the Gallbladder. Sonographic Appearance: Dilatation of the Intrahepatic and CHD. Normal CBD Hyperechoic Intraluminal Focus Posterior Acoustic Shadowing Mobile WES 9. Porcelain Gallbladder Refers to Calcification of the Gallbladder Wall complicating Chronic Cholecystitis. US demonstrates a Highly Echogenic Wall with Acoustic Shadowing. 7. Chronic Cholecystitis Porcelain Gallbladder: is a predisposing condition to Gallbladder Carcinoma. Decrease in the Vascular Supply to the Gallbladder. Etiology: Recurrent Inflammation secondary to Infection. Clinical Findings: Asymptomatic, Vague RUQ Pain. Obstruction of the Cystic Duct, Infection, Idiopathic. Clinical Findings: Severe Epigastric Pain, RUQ Pain Biliary Colic, Positive Murphy Sign, Nausea, Vomiting, Jaundice, Elevated AST, Bilirubin, and Alkaline Phosphatase. Sonographic Appearance: Pancreas Gallstones 95% Elongated, lying Transverse and Obliquely in the Epigastric and Hypochondriac Regions. Hyperechoic Wall Retroperitoneal Organ. Marked Posterior Acoustic Shadowing 10. Wall-Echo-Shadow (WES) Function of Pancreas Exocrine When the Gallbladder is completely filled with Gallstones, a confident diagnosis becomes Amylase: breaks down carbohydrates. more difficult because the Gallbladder resembles an Air-Filled Loop of Bowel. Lipase: breaks down fats. WES sign is definitive evidence of a Stone-Filled Gallbladder. Trypsin: breaks down proteins into amino acids. Gallstones: produce a clean dark shadow. Cholecystokinin: stimulate secretion of pancreatic enzymes and gallbladder contraction. Air: produces a dirty brighter shadow. Gastrin: stimulates secretion of gastric acids. Secretin: stimulates secretion of bicarbonate. Function of Pancreas Endocrine – Secrete Hormones directly into the Bloodstream. Alpha Cells: secrete glucagon. Beta Cells: secrete insulin. Delta Cells: secrete somatostatin. Division and Location of Pancreas 11. Gallbladder Hydrops Head Etiology: Obstructed Cystic Duct, Biliary Stasis, Surgery, Hepatitis, Gastroenteritis, Diabetes. Lies in the Descending Portion of the Duodenum. Clinical Findings: Asymptomatic, RUQ pain, epigastric pain, palpable mass Lateral to the Superior Mesenteric Vein and Anterior to the Inferior Vena Cava. Main Portal Vein and Hepatic Artery lie Inferior to the Pancreatic Head. Sonographic Appearance: CBD is situated in the Posterolateral and Inferior Portion of Pancreatic Head. Enlargement. Gallbladder diameter exceeding 5 cm. Body: Largest, most Anterior Aspect. Thin Hyperechoic Walls Anterior to the Aorta, Superior Mesenteric Artery, Splenic Vein, Left Renal Vein and Spine. Posterior to the Antrum of the Stomach. Tail: Most Superior Portion of the Pancreas. Anterior and Parallel with Splenic Vein. Anterior to the Upper Pole of Left Kidney, Posterior to Stomach, Lateral to the Spine. Extends toward the Spleen. Pancreatic Ducts Abnormal Pancreatic Duct Irregular Non-Parallel Hyperechoic Walls. Measurement exceeding 3 mm in the Head / Neck or 2 mm in the Body. Examination Technique Begin with transducer Perpendicular at the Midline of the body, inferior to the Xiphoid Tip. Slowly slide the probe inferiorly. Locate the Pancreatic body. Move the probe to the left lateral to visualize the Tail. Move the probe to the right lateral to visualize the Head. Indication for Ultrasound Examination Sonographic Appearance Severe Epigastric Pain Normal Pancreas and Size in Ultrasound Elevated Pancreatic Enzymes Biliary Disease Smooth Homogenous Parenchyma Abdominal Distension with Hypoactive Bowel Sounds Adult Pancreas is either Isoechoic or Hyperechoic when compared to normal Liver. Pancreatitis Young Children: Hypoechoic Weight Loss Older Adults: Hyperechoic Anorexia Head: < 3.0 cm Body: < 2.5 cm Tail: < 2.5 cm Pancreas Neoplasm Pathology 1. Acute Pancreatitis Etiology: Biliary Disease, Alcohol Abuse, Trauma, PUD, Idiopathic Clinical Findings: Abrupt Onset of Epigastric Pain, Nausea, Vomiting, High Lipase, Amylase Sonographic Appearance: Decrease in Parenchymal Echogenicity Smooth Borders Enlargement Abnormal Pancreas Irregular or Heterogenous Parenchyma with Calcifications. Normal Pancreatic Duct 2. Chronic Pancreatitis Anechoic Non-Vascular Tubular Structure. Etiology: Repeated Persistent Attacks of Pancreatitis, Hypocalcemia, Hyperlipidemia. Smooth Parallel Hyperechoic Walls < 3 mm in the Head. Clinical Findings: Chronic RUQ Pain or Epigastric Pain, Nausea, Vomiting, Weight Loss, Abnormal Glucose Tolerance Test, Normal Amylase and Lipase Values. Sonographic Appearance: Spleen Increase in Parenchymal Echogenicity Pseudocyst Formation Function of the Spleen Irregular Borders Atrophy Removes Foreign Material from Blood. Calcifications Prominent Pancreatic Duct Major Destruction Site of old Red Blood Cells. Red Blood Cells are Removed and Hemoglobin is Recycled. Reservoir for Blood. Sonographic Appearance of Spleen Moderately Echogenic and Homogenous Parenchyma. Isoechoic to slightly Hypoechoic compared to the normal Liver Parenchyma. Smooth Borders, Well-defined and commonly Lobulated. 3. Pancreatic Cyst Etiology: Congenital Anomalous Development of the Pancreatic Duct. Clinical Findings: Asymptomatic, Dyspepsia, Jaundice Sonographic Appearance: Anechoic Mass Smooth Borders Normal Values of the Spleen Posterior Acoustic Enhancement Superior to Inferior Axis: < 13 cm Medial to Lateral Axis: 6 - 7 cm Anterior to Posterior Plane: 5 - 6 cm Sonographic Appearance Longitudinal Diameter (L): is the greatest dimension of the Spleen on a Longitudinal image through the Hilum. Transverse Diameter (T): is the greatest dimenson of a transverse image through the Hilum. Diagonal Diameter (D Thickness): measured in Transverse image through the Hilum as the distance from the Hilum to the Outer Convex Surface, approximately Perpendicular to the 4. Pancreatic Carcinoma Transverse Diamter. Adenocarcinoma 90% of cases. 75% involve the Head of the Pancreas. 20% involve the Body. Clinical Findings: Abdominal Pain, Back Pain, Weight Loss, Jaundice, Anorexia, Diabetes. Sonographic Appearance: Hypoechoic Mass in the Pancreas. Irregular Borders Dilated Biliary Tree Hydrophic Gallbladder Technique Urinary System Spleen is best visualized with Posterolateral Intercostal Approach. Kidneys, Ureters & Urinary Bladder. Begin scanning with the transducer Perpendicular in the Most Inferior Intercostal Space. When patients hold their breath, the Superior and the Inferior Margin of the Spleen can be visualized from this Intercostal Space. Functions of the Urinary System Indications for Examination Produces Urine and Erythroprotein. Influences Blood Pressure and Blood Volume. Chronic Liver Disease Palpable Mass Regulates Serum Electrolytes. Infection Abdominal Pain Regulates Acid Base Balance. Leukocytosis Fatigue Leukopenia Trauma Pathology 1. Accesory Spleen (Splenules) Appear as Rounded, Well- Defined Masses in or near the Splenic Hilum. They are Homogeneous and Isoechoic with Spleen Parenchyma. Kidney Anatomy Renal Capsule: Fibrous Capsule surrounding the Cortex. Renal Cortex: Outer portion of the Kidney. Medulla: Inner portion. Where the Renal Pyramids are found. Column of Bertin: Inward extension of the Renal Cortex between the Renal Pyramids. Renal Sinus: Central portion of the Kidney. Renal Hilum: Contains the Renal Artery, Renal Vein and Ureter. 2. Splenomegaly Normal Renal Sizes Etiology: Length: 9.0 - 13.0 cm Congestive Heart Failure Diabetes Mellitus Width: 4.0 - 5.0 cm Cirrhosis Hypertension Height: 2.5 - 3.0 cm Infection Trauma Cortical Thickness: minimum of 1 cm. Normal Pediatric Renal Sizes Indications for Examination Pedia: length 7.0 - 8.0 cm. Increase in Creatinine or BUN Levels. Infant: length 5.0 - 6.0 cm. Urinary Tract Infection Flank Pain Sonographic Appearance (Adult) Hematuria Renal Capsule: Well-defined Echogenic Line surrounding the Kidney. Hypertension Renal Cortex: Fine, Moderate to Low Level Echogenicity. Decrease in Urine Output Renal Sinus: Innermost part, Greatest Echogenicity. Trauma Anatomical Variants Kidneys 1. Dromedary Hump Demonstrated most often on the Left. Asymptomatic Sonographic Appearance: Lateral outward Cortical Bulge. Echogenicity equal to the Cortex. Sonographic Appearance (Pedia) Renal Capsule: Sparse amount of Perinephric Fat make it difficult to distinguish the Capsule Renal Cortex: Moderate to Highly Echogenic. Renal Sinus: Barely visible Renal Sinus. Medulla: Commonly Anechoic. 2. Pelvic Kidney Failure to Ascend. Asymptomatic, Pelvic Pain. Sonographic Appearance: Preparation Elongated core of Echogenic Tissue surrounded by less Echogenic Parenchyma. Kidneys: patients should be Hydrated. Located in the Lower Abdomen or Pelvis. Renal Vessels: Nothing by Mouth for 6 - 8 hours before the examination. Bladder: drink 8 - 16 ounces of Water before the examination. Patient Position Supine RPO LPO Right Lateral Decubitus Left Lateral Decubitus Prone Pathology 4. Exophytic Cyst 1. Renal Cyst: Asymptomatic Found in 50% of patients over 55 years. Sonographic Appearance: Anechoic Hyperechoic Thin Walls Smooth Margins Enhancement 5. Polycystic Kidney Disease 2. Parapelvic cyst Inherited Disorder, Normal Renal Parenchyma is replaced with Cysts. Originating from the Renal Parenchyma. Clinical Findings: Palpable Abdominal Mass, HPN, Hematuria, Colicky Pain, elevated BUN Asymptomatic, HPN, Hematuria and Creatinine. Sonographic Appearance: Polycystic Kidney Disease (Adult) Anechoic Mass in the Renal Hilum. Sonographic Appearance: Hyperechoic Thin Walls Smooth Margins Multiple Cysts Enhancement Irregular Margins Normal Renal Parenchyma may not be visualized. 3. Peripelvic Cyst: Asymptomatic Polycystic Kidney Disease (Pedia) Sonographic Appearance: Inherited Disorder, Normal Renal Parenchyma replaced with Cysts. Anechoic Mass near or around the Renal Pelvis. Clinical Findings: Palpable Abdominal Mass, HPN, Hematuria, Colicky Pain. Hyperechoic Thin Walls Smooth Margins Sonographic Appearance: Enhancement Bilateral, Hyperechoic Enlarged Kidneys 6. Chronic Renal Failure Etiology: Glomerulonephritis, HPN, Vascular Disease, DM, Chronic Hydronephrosis. Clinical Symptoms: Elevated BUN, Creatinine, Proteinuria, Polyuria, Headache, Fatigue, Weakness, Anemia. Renal Parenchymal Disease Sonographic Appearance: Renal Atrophy 9. Wilms Tumor Hyperechoic Parenchyma Beckwith Wiedemann Syndrome Abdominal Pain Thin Renal Cortex Hemihypertrophy Nausea and Vomiting Difficult to distinguish from surrounding. Male Prevalence Gross Hematuria 7. Hydronephrosis Palpable Mass Hypertension Water inside the Kidney. Refers to Distension and Dilation of the Renal Pelvis and Calyces. Sonographic Findings: Caused by Obstruction of the Free Flow of Urine from the Kidney. Predominantly Solid Mass Etiology: Obstruction of Urinary Tract. Echogenic Rim Clinical Findings: Flank Pain, Hematuria, Fever, Leukocytosis. Calcification Stages of Hydronephrosis Grade 1 Mild: Slight Dilatation of Renal Calyces Grade 2 Moderate: Extensive dilatation of the Calyces. Thinning of the Renal Pelvis. Grade 3 Severe: Massive dilatation of the Calyces. Loss of Renal Parenchyma. 10. Angiomyolipoma Composed of Fats, Blood Vessel and Muscle. USD appearance of AML, seen in 80% of cases, is a Uniformly Hyperechoic Renal Mass with Sharp Borders. The Echogenicity of the mass is at least equal to that of Renal Sinus Fat. Clinical Findings: Asymptomatic, Flank Pain, Gross Hematuria. 8. Nephrolithiasis Sonographic Appearance: Calculi in the Kidneys. Etiology: Urinary Stasis. Well Defined Hyperechoic Mass Clinical Findings: Asymptomatic, Renal Colic, Flank Pain, Hematuria. May Distort Renal Architecture Sonographic Appearance: Hyperechoic focus within the Kidney. Posterior Shadowing. Urinary Bladder 2. Bladder Ureterocele Normal Bladder Wall Thickness Clinical Findings: UTI, Asymptomatic 3 mm when distended. 5 mm when empty. Sonographic Findings: Hyperchoic Septation seen within the Bladder at the Ureteric Orifice. Ureters enter the Bladder Wall at an Oblique Angle 5 cm above the Bladder Outlet. Demonstrated when Urine enters the Bladder. Post Void: 20 ml. 3. Urinary Bladder Calculus Etiology: develops in the Bladder, migrates from the Kidneys. Preparation Clinical Findings: Asymptomatic, Hematuria. Bladder must be Full. Give 4 - 5 glasses of Fluid and do not allow patient to Micturate. Sonographic Appearance: Normal Sonographic Appearance Hyperechoic Focus within the Urinary Bladder. Anechoic Fluid-Filled Structure located in the Pelvic Midline. Posterior Shadowing Bladder Wall Thickness depends on Urinary Bladder Distention but should not exceed 5 mm. Mobile with Patient Position Change. Pathology 1. Urinary Bladder Diverticulum Clinical Findings: Asymptomatic, UTI, Pelvic Pain. Sonographic Appearance: Anechoic Pedunculation of Urinary Bladder. 4. Cystitis Neck of Diverticulum is Small. Clinical Findings: Dysuria, Urinary Frequency, Leukocytosis. May Enlarge when Bladder Contracts. Appear as Fluid-Filled Sacs that project from the Bladder Wall. Sonographic Findings: Bladder Mucosa herniates through a defect in the Bladder Wall, producing a Fluid-Filled Mass that communicates with the Main Bladder Lumen through a Small Orifice. Increase in Bladder Wall Thickness Mobile Internal Echoes Irregular Walls